Basic Information
Provider Information | |||||||||
NPI: | 1124014758 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KELLY | ||||||||
FirstName: | LAWRENCE | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12361 W BOLA DR | ||||||||
Address2: | SUITE 100 | ||||||||
City: | SURPRISE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853789021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6235845626 | ||||||||
FaxNumber: | 6235848998 | ||||||||
Practice Location | |||||||||
Address1: | 12361 W BOLA DR | ||||||||
Address2: | SUITE 100 | ||||||||
City: | SURPRISE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853789021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6235845626 | ||||||||
FaxNumber: | 6235848998 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2005 | ||||||||
LastUpdateDate: | 06/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 27172 | AZ | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0005X | 35083 | AZ | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 5920416 | 01 | AZ | AETNA | OTHER | P00188666 | 01 | AZ | RAILROAD MEDICARE | OTHER | 2036792 | 01 | AZ | UNITED HEALTHCARE | OTHER | 2Z1651 | 01 | AZ | HEALTHNET | OTHER | 1124014758 | 01 | AZ | AHCCCS | OTHER | P0836100 | 01 | AZ | BCBS OUT OF AREA | OTHER | 514829 | 05 | AZ |   | MEDICAID |